E-Free Youth Waiver and Medical Release FormOvernight events/Field trips/Special Events Name of child * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian's Email Phone number (###) ### #### Parent/Guardian's phone number * (###) ### #### Does your child have any severe allergies, such as anaphylactic reactions to animal toxins (e.g., bee stings), chemical toxins, food, or ingredients (e.g., peanuts), drugs (e.g., Penicillin) or other agents? * Yes, life-threatening Yes, but not life-threatening No known allergies If yes, please explain Does your child have any medication with him/her? * Yes No If yes, please explain Does your child have any physical, emotional, mental or behavioral concern or limitations that our leaders should be aware of? * Yes No If yes, please explain Please check any of the following that your child has or has had in the last 3 months: * Appendicitis Epilepsy Diabetes Rubella Ear infection Hepatitis Measles Hay fever Severe stomach ache Sinusitis Mumps Tonsillitis Chicken Pox Asthma Bedwetting Fainting Other None of the above If other, please explain Precautions are taken for the safety and health of your child, but in the event of accident or sickness, Wainwright Evangelical Free Church, its staff and its volunteers are hereby released from any liability. In the event that your child requires special medications, x-rays or treatment, the parents/guardians will be notified immediately. Your child must be covered by Provincial Health Insurance or equivalent medical insurance. * Name of family physician Physician's phone number (###) ### #### Permission to communicate with youth and parents/guardians regarding youth events through WhatsApp messenger? * Yes No By completing the fields below, I hereby confirm that I am the parent or guardian of the named child/dependent, and that I give permission for him/her to be transported for youth activities on behalf of the Evangelical Free Church (EFC) Wainwright by the individuals deemed eligible by the EFC Wainwright. * Parent/guardian's name First Name Last Name * Child's name First Name Last Name Date * MM DD YYYY Thank you! Your response will be forwarded to the Youth Leadership Team.
